Lower limb amputation refers to the removal of part or the whole lower extremity. It is a life changing procedure to the patient as well as relatives and friends. The decision to amputate a patient is a last resort owing to limb salvage failure. This procedure affects people's abilities especially walking, participation in valued activities, body image perception and quality of life. Amputating the lower limb is not an easy decision to reach at. Though not easy to arrive at the decision of amputating the limb, the following may necessitate it:

  • Preserving life
  • Reducing pain
  • Restoring function
  • Improving the quality of general health

Management a patient with a lower limb amputation equires team approach to cater for their pysical and emotional needs. Some of the important team members for the management of lower limb amputees include:

  • Physiotherapists
  • Occupational Therapists
  • Nurses
  • Psychologists
  • Prosthetics
  • Social workers and many significant others

Causes of Lower Limb Amputation

  • Traumatic

    Traumatic injuries that lead to degloving and crushing injuries

  • Non-traumatic

    Non traumatic causes of lower limb amputation include:

    • Infection such as chronic leg ulcer leading to septicaemia
    • Arterial insufficiency leading to gangrene
    • Malignancy e.g cancer of the bones (osteosarcoma) and other sarcomas
    • Diabetes mellitus
    • Frostbite
    • Renal (kidney) disease
    • Congenital problems

    Congenital causes of amputation may include being born with a shortened lower limb that may call for a surgical removal. One typical example of this is phocomelia. Phocomelia is a congenital deformity in which the limbs are extremely shortened so that the feet and hands arise close to the trunk.

The level of amputation depends on the possibility of healinng (tissue viability) of the remaining part. Other points that are also important to consider while deciding the level include length of the stump (residual limb), function and cosmetic outlook.

General Management of the amputee

Management of patients with major lower limb amputation targets three main goals:

  • Improving quality of life
  • Rducing pain
  • Functional restoration
It must also be apppreciated that not all amputees will need a prosthesis. A multidisciplinary team can help to develop the best management for the amputee. Before thinking of a prosthetic limb, it important to find out if the patient want to walk again. It is also crutial to investigate the posibility of walking with a prosthetic leg. The other fundamental part to be looked into is the home setting if there is anyone to help the patient.

Physiotherapy Management

Physiotherapy management of an amputee spans in all areas of the patient's life. Management focuses on physical, psychological and social needs. Patient care must not centre on the physical needs only. The care must use a rehabilitation approach whereby all patient needs are taken into consideration. Physiotherapy as a profession that strives to improve quality of life and independnce dwells much in making sure that the patient achieves as much as he can in becoming independent while using the amputated limb.

A physiotherapist will make sure that:

  • Your general good health is achieved
  • Your functional outcome status is optimized
  • Pain is reduced
  • Complications have been prevented
Amputation management takes four main stages:
  • Pre-operative
  • Postoperative
  • Assessment for prosthetis suitability
  • Prosthetic rehabilitation

In the Preoperative Stage, physiotherapy involving monitoring respiratory and musculoskeletal status, physical, psychological and social status. Past medical, drug and social history and premorbid mobility are noted. An explanation of postoperative regimen is offered to the patient so that they understand what is to foollow.

In the Postoperative Stage, the following points should not be forgotten:

  • Monitoring cardiorespiratory status
  • Bed mobility exercises
  • Mobility and strengthening exercises for the residual limb and trunk
  • Assessment for walking aid and transfers
  • Assessment for wheelchair use
  • Balance and posture re-eucation
  • Stump care and pain relief

In the Assessment for prosthesis suitability stage, the above points must be taken into consideration plus the following:

  • Use of pneumatic post amputation mobility (PPAM) aid 7 -10 days postoperatively
  • Gait, posture and balance re-education
  • Activities of daily living (ADLs)

In the last stage, Prosthetic rehabilitation stage, the following should be added to the above list:

  • Prosthetic management
  • Continuing gaitre-education
  • Promotion of functional independence
  • Stump care

Contractures must be avoided at all cost becaus they will hault the process of prosthetic rehabilitation stage. It may become hard for the amputee to utilize a prosthesis in presence of contractures.

It is important to educate the patient on what he or she can do in order to prevent contractures. Physiotherapeutically, contractures can be prevented via exercise and positioning.

Tidy's Physiotherapy 13th Edition, page 509 provides a sample postoperative plan of physiotherapy care.

Duration (In days) Plan of care
Day 1: Patient is in bed Maintain respiratory parameters
Exercises targetting strength, mobility and balance
Pain control
Day 2: Sitting in the Chair Strengthening exercises (e.g. static quadriceps, upper limb exercise, knee flexion, bridging)
Training balance
Practicing Transfers
Prevention of contractues
Assessment for wheelchair
Day 2-3: Standing with a walking frame Posture management
Balance training
Day 3-4: Walking with a waling frame Stump maintenance
Transfer work
Balance work
Day 7-10: Early walking Begin early walking with PPAM aid
Re-education inthe gym: posture, balance work
Continue contracture prevention and stump car
Day 10 Discharge or transfer to rehabilitation unit
Prosthetic assessment

Psychological implications of amputation

All healthcare workers must nderstand the implication of an amputation in a patient. Body image perception is even more profound than the functional loss itself. It is essential for a physiotherapist to understand the grieving process so that they can assist their patients appropriately.

For specific physiotherapy interventions, click here

Pain in Amputation

One of the problems that people face after an amputation is pain. This pain manifests itself in two different ways:

  • Residual limb pain
  • Phantom pain
Residual limb pain may originate from different causes: neuroma (a nodule formed at the end of a cut nerve nerve that folds on itself and form an enlargement)
Pain may also be experinced postoperatively
Another pain felt may originate from the prosthesis itself when it not fitting well.

Phantom pain is a distressing kind of pain that isfelt in the amputated part as if it were stil existing. Phantom limb pain increases with age and it also associated with psychological factors. Patients/amputees may describe this pain as:

  • Squeezing
  • Burning
  • Sharp
  • Shooting

Outcome Measures In Amputation

Like in any other branch of physiotherapy management, outcome measures help the therapist to measure the effect of their intervention. The following are some of the outcome measures that may be used in the field of amputation rehabilitation:

  • Rivermead Mobility Scale
  • Functional Measures for Amputees
  • Prosthetic Profile of Amputee (PPA)
  • Houghton Scale

Cardiopulmonary Physiotherapy
Chimwemwe Masina, PT

Author: Chimwemwe Masina

Chimwemwe Masina is currently working as a Resident Physiotherapist at DDT College of Medicine in Gaborone, Botswana. Before joining DDT College of Medicine, he worked in the Ministry of Health at Kamuzu Central Hospital in Malawi, MagWaz Physiotherapy and Wellness Services in Lilongwe, Malawi. as well as Volunteering at Physiopedia.
His interest is in Neuromusculoskeletal Physiotherapy and currently he is an assisting lecturer in Manual Therapy and Lumbar Spine Management.

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